What constitutes a “perfect” family planning program? And what would it take to make a perfect program a reality? The answer is complicated.
At a time in history when most people’s dreams are colored by fears of a global pandemic, perhaps it is appropriate to spend a few minutes dreaming about what a “perfect” voluntary family planning program would look like. Isn’t it better to spend time on good dreams rather than nightmares?
We thought it was an exercise worth doing.
A good starting place is with the 10 Elements of Family Planning Success created just over 10 years ago. At that time, there was little consensus on what constituted an effective international family planning program and so the Johns Hopkins Center for Communication Programs (CCP), under the Knowledge for Health (K4Health) Project, gathered the experiences of some 500 family planning professionals from nearly 100 countries to figure it out. Through an online survey and discussion forum, the project identified 10 essential components, ranging from supportive policies and evidence-based programming to effective communication, client-centered care, and affordable care.
The High Impact Practices in Family Planning (HIPs) grew, in part, out of this initiative. A small group of experts were tasked with “identifying a short list of HIPs [or specific family planning interventions] that, if implemented at scale, would help countries address the unmet need for family planning and thereby increase national contraceptive prevalence.” The 12 original HIPs have since been revised into a set of evidence-based voluntary family planning practices that cover everything from enabling environments to service delivery to social and behavior change. They are endorsed by some 30 organizations and supported by briefs, planning guides, and webinars.
This of course begs the question: If a voluntary family planning program were to implement all the HIPs, would that result in the “perfect” family planning program?
The answer is, as are most things these days, complicated.
“We must aim for perfection and remain stubbornly optimistic in the ambitious pursuit of universal contraceptive access and autonomy,” says Megan Christofield, Technical Advisor, Family Planning, at Jhpiego. “But knowing that we will fall short, the critical question then is where we can and cannot tolerate imperfection. For example, contraceptive coercion and the overt discrimination to family planning access that is levied towards certain groups like sexual or religious minorities cannot be tolerated.”
Fatou Diop, FP2020 Youth Focal Point, with the National Youth Alliance for Reproductive Health and Family Planning in Senegal, tends to agree: “To make a perfect family planning program, the first thing to do is to involve the beneficiaries in both the design and the implementation. Even if we don’t reach the perfect family planning program, we must continue to work for women and girls. Indeed, it is by continuing the work and always trying to go further that we will one day arrive at perfection.”
A total of 79 respondents from 31 countries working in voluntary family planning provided their thoughts on what characteristics comprise a “perfect” family planning program. As expected, all the original 10 Elements of Family Planning Success were considered essential, with most respondents choosing all of them. By the smallest margins, the top three characteristics were: evidence-based programming, strong leadership and management, and effective communication strategies. French-speaking respondents also listed supportive policies and high-performing staff in their top characteristics. A strong point of agreement among all respondents was the importance of addressing youth and involving them in all programs and projects.
Two respondents – one from the UK and one from Kenya – pointed to the Get Up Speak Out (GUSO) program developed by Netherlands/UK Consortium partners as an example of a near-perfect program. Said one, “The programme worked purposefully to create an enabling environment for SRHR [sexual and reproductive health and rights]. It brought together organizations with complementary strengths (i.e., service provision, education, legal advocacy, campaigning) and engaged two coordinators at National level to mediate between them. Learning was shared across countries.” Another respondent said, “The program built the capacity of health care workers to provide youth-friendly services so as to improve quality of and access to a wide range of SRHR [care].”
Dinar Pandan Sari, Program Officer with CCP in Indonesia, calls out the PilihanKu/My Choice project in Indonesia, a comprehensive demand-supply intervention. “We went from an authoritarian system in the 1980s … when the government was the only source for information. Now information is distributed through various channels. But challenges remain when we want to scale up from the pilot experience to nationwide implementation. There are problems of mentality and mindset, openness, leadership, and sometimes time.”
Paul Nyachae, Jhpiego’s Program Director, The Challenge Initiative (TCI), East Africa, points to the need for holistic programming as well as a willingness to take risks as essential ingredients for scale-up, as demonstrated through the Kenya Urban Reproductive Health Initiative. The program, launched in 2010, showed a 12 percentage point increase in the modern contraceptive prevalence rate among women, according to Nyachae. “The success of this program was attributed to the fact that it addressed concurrently the Service, Demand and Advocacy, and Enabling Environment that are necessary for planning to succeed,” he says. “The flexibility to implement and test various interventions with no punitive measures for failure was a key ingredient in success as was being able to distill the most impactful interventions to scale up.”
Building on the demonstrated success of this and other regional programs of the Urban Reproductive Health Initiative, TCI now aims to rapidly and sustainably scale up proven reproductive health solutions among the urban poor in East Africa, Francophone West Africa, Nigeria, and India. Dawood Alam, Senior Specialist, Community Mobilization and Social & Behavior Change, with EngenderHealth in India, points to TCI as a program that is working: “The Challenge Initiative (TCI) led by the Gates Institute in India partnered with the Government to activate family planning programs in urban areas.”
Respondents were thoughtful in thinking through what components were vital for a “perfect” family planning program.
“The involvement of all segments of the population, from women of childbearing age through spouses and finally community and religious leaders in their role as influencers …”
“Anchored in the community, directed by beneficiaries, non-stigmatizing communication, diversified client-centered service delivery strategy. Takes into account the challenges of accessing marginalized groups.”
“A versatile program with several multidisciplinary and transversal actors. Existence of several distribution channels with several multi-purpose providers in both family planning and integrated services (cervical cancer screening or STI/HIV/AIDS screening.)”
“Human rights-based, evidence-based programming and services accessible to affected youth and adult populations.”
“Sensitizing the political and administrative authorities and partners responsible for national and international organizations working in prisons, mining areas and conflict zones under siege by armed groups to be able to supply reproductive health products to improve the health of mothers and children as well as girls in these areas.”
“Most family planning programs are on a Copy-Paste Spree,” says Ehtesham Abbas, Director of Programs and Operations for CCP Pakistan. “Following the evidence is not about replicating earlier programs but evolving further. The best family planning programs will be the ones trying to do things unheard of. For example, increasing access to a population that previous programs didn’t, increasing [access to] modern contraceptive methods that previous programs didn’t, addressing a specific barrier that previous programs didn’t … The ability of a program to swim against the tide determines its trajectory.”
When asked about the three biggest challenges to establishing a “perfect” voluntary family planning program, most responses mentioned lack of access to family planning care, funding, and the need for better communication efforts.
“It is necessary to involve religious and opinion leaders, work to break down all the barriers that can hinder the promotion of family planning, engage male partners, and have good family planning programs and intervention strategies.”
“You must take into account the real needs of beneficiaries, according to a real – and not fictitious – community approach.”
“Place family planning services on the Ministry of Health’s list of priorities.”
“Have dedicated staff/providers who understand their mission to serve the population, especially those with unmet family planning needs.”
“A clear, actionable vision, a theory of change that maps what needs to change in order to achieve that vision, data to help monitor progress toward that goal and adjust the theory of change as needed, and sustained political commitment to that vision” are the requirements for a “perfect” voluntary family planning program in the eyes of Shawn Malarcher, Senior Best Practices Utilization Advisor, Office of Population and Reproductive Health at USAID.
Professor Jane T. Bertrand with the Tulane School of Public Health and Tropical Medicine currently works on family planning projects in the Democratic Republic of Congo. She believes that sometimes we have to look back to find what truly works: “In the early days of international family planning (starting in the mid-1960s), the Profamilia program in Colombia came as close as I have witnessed to being ‘perfect.’ The organization dedicated itself to its mission of making contraceptives available to women and men of all economic levels, even in remote parts of the country … Profamilia was client-centered two decades before the Cairo Conference made this a watchword for family planning programs. It used data to manage and adapt its programs, far before the term evidence-based came into vogue. As the organization matured, it found creative solutions to the problem of limited resources, using profits from its social marketing program to cross subsidize family planning for low-income clients.”
Dr. Ngong Jacqueline Shaka, CEO of Youth 2 Youth, and FP2020 Youth Focal Point from Cameroon, admits that she has not found any family planning program that comes close to perfection. But she knows the qualities that would make one so: equity, access, affordability, and knowledge sharing. Additionally, she says, “Leveraging contextualized data for advocacy by reaching those with unmet needs, prioritizing the needs of adolescents, empowering the people/communities to take charge of the program, and equitable funding opportunities” are key.
While most family planning experts agree that the “perfect” voluntary family planning program doesn’t exist, and may never, it is often because of factors over which we have little control. Shifting populations of women and girls of childbearing age, climate emergencies, pandemics, changes in governments can all arise and affect the best efforts of those who provide voluntary family planning. But most people who responded to our outreach believe that there is no harm in striving for perfection and getting as close as possible.
“We absolutely must keep trying,” states Lynn M. Van Lith, Technical Director for Breakthrough ACTION. “Even when not perfect, as long as we are listening deeply to what women and girls want and need related to meeting their reproductive intentions, whatever they may be.”
And Maryjane Lacoste, Senior Program Officer, Family Planning, Bill & Melinda Gates Foundation, reminds us that all family planning programs must be agile and prepared for the unexpected: “The ongoing COVID-19 pandemic has shown us that in times of crisis, women and girls are especially vulnerable as essential health services like family planning become increasingly disrupted and tens of millions of women and girls lose access to contraception. Effective programs have been able to meet this moment by ensuring women and girls can access contraceptives, counselling and information outside of facilities and via mobile and digital platforms. The current work that is being done through donor partnership to support countries with introduction and scale up of DMPA-SC self-injection is key to a self-care approach that becomes more critical in the context of a pandemic such as COVID-19.”
From the many family planning experts who responded to our survey, it is clear that “perfect” may never be used to describe a voluntary family planning program, despite our best efforts. It is a moving target, and the best we can hope for is to strive to meet the needs of as many women and girls as possible. It’s good every year for each of us to gauge our progress toward improving family planning programs to meet the needs of all women and girls. It is the journey toward perfection that is more important than the destination.